Bilateral bipartite lunate misdiagnosed as carpal fracture: a case report and brief review of literature.

Bilateral bipartite lunate is a very rare congenital anomaly of the lunate. A 36-year-old military European male was referred to our service diagnosed with a lunate fracture. Symptoms began 3 months before our encounter, after falling on his outstretched left hand. The patient was misdiagnosed with a lunate fracture, therefore treated with a cast and then transitioned to a removable splint over 2 months in total; When the patient presented to our facility, on physical examination, he referred pain over the dorso-ulnar side of the wrist, especially the ulnar snuff. Tenderness to palpation over the fovea and positive triangular fibrocartilage complex axial compression test was encountered. Bilateral wrist X-rays were taken, and a diagnosis of bilateral bipartite lunate was made by our team. The patient was treated for ulnar-sided wrist pain with steroid injection and physical rehabilitation. A literature review on bipartite lunate was conducted, and cases share three basic common features: unilateral involvement, incidentally diagnosed after a traumatic event, and absence of positive clinical findings related to the bipartition.

[Os epilunatum is a rare cause of atraumatic impaired motility and wrist pain].

In this case report a 28-year-old man had a six-year history of atraumatic wrist pain. X-ray and MRI showed an accessory ossicle dorsal to the lunate, near the scapholunate ligament: an os epilunatum. Os epilunatum is a rare ossicle of the hand, and only one clinical case and few cadaveric studies have previously been reported. Resection was performed through a dorsal approach, without damaging the scapholunate ligament. Three months post-operatively the patient had increased motility of the hand and no pain.

Bipartite lunate incidentally noted on radiographs obtained for skeletal age estimation: A report of two cases.

Bipartite lunate is a rare congenital anomaly of carpal bones. We present a report of two cases where children referred for determination of skeletal age were incidentally found to have bipartite lunate. In both cases, radiographic appearance of lunate could have been mistaken for secondary centres of ossification in other carpal bones. It is imperative for all radiologists to be aware of this rare congenital anomaly in order to avoid pitfalls in clinical diagnosis.

Inter- and intrarater reliability of ulna variance versus lunate subsidence measurements in Madelung deformity.

PURPOSE: To assess inter- and intrarater reliability of both ulna variance and lunate subsidence measurement methods in a large consecutive series of children with Madelung deformity. METHODS: Ulnar variance and lunate subsidence were measured on 41 standard anteroposterior wrist radiographs from 31 patients with Madelung deformity. The patients had a mean age of 13 years (range, 5-25) at the time of presentation. Two pediatric orthopedic hand/upper limb surgeons evaluated all radiographs twice in a 4-week interval using standard digital imaging software. Intraclass correlation coefficients (ICCs) were calculated for inter- and intrarater reliability, and results were reported using the Landis and Koch criteria. RESULTS: The interrater ICC for the ulna variance measurements was substantial, and for the lunate subsidence almost perfect. The intrarater ICC for ulna variance was substantial for both raters. In contrast, the intrarater ICC for lunate subsidence was almost perfect for both raters. CONCLUSIONS: Measurement of lunate subsidence showed both superior interrater and intrarater reliability compared with the ulnar variance method. Whenever relative ulna length is assessed in children and adolescents with Madelung deformity, the lunate subsidence should be the preferred method to characterize deformity.

Radiological and clinical analysis of Madelung's deformity in children.

INTRODUCTION: Madelung's deformity is a bone dysplasia that occurs predominantly in adolescent females, characterized by early epiphyseal growth arrest in the medial part of the distal radius. This leads to an upward and medial displacement of the radial joint surface, restricting range of motion. OBJECTIVES: The objective of this study was to determine whether there was a link between clinical and radiological data in children with Madelung's deformity and to test the hypothesis of a relation between the deformity and a genetic mutation. METHODS: A retrospective study recruited 13 patients with Madelung's deformity, with a mean age of 13.2 years (range, 8-18 years). Assessment comprised level of pain, range of motion and grip force, with standard AP and lateral wrist X-rays. Every patient except one underwent molecular genetic screening, adhering to current recommendations. RESULTS: Pronation-supination, radial inclination and grip force were significantly impaired compared to normal results. All X-ray measurements were significantly abnormal, except for the lunate-covering ratio. Genetic mutation (SHOX) was systematic in the 12 patients screened. DISCUSSION: Radiological deformity did not correlate with functional disturbance or pain. Non-acquired Madelung's deformity requires molecular screening for SHOX or XO mutation, which definitively diagnoses Léri-Weill dyschondrosteosis or Turner syndrome. CONCLUSION: A larger series is necessary to confirm these preliminary results, which nevertheless suggest that non-acquired Madelung's deformity is not isolated but syndromic. Early detection of Léri-Weill or Turner syndrome is essential, due to their therapeutic specificities. LEVEL: IV.

Radiological investigation of relationship between lunate type and ulnar variance.

UNLABELLED: Some variances and anatomical proportions of the wrist may contribute to development of avascular necrosis of the lunate. Kienböck's disease is more often encountered in young males, who suffer, among others, from type II of the lunate (with two joint surfaces for the capitate and hamate) and/or negative variance of ulna in relation to radius. The aim of the study was to investigate whether there exists interdependence between the simultaneous occurrence of individual types of the lunate with one of the variances of ulna in both genders. MATERIAL AND METHODS: A retrospective analysis of 394 (n=394) radiological tests of the wrist in 174 (44%) women and 220 (56%) males aged 18-83 years (average age 39 years). From the entire pool, 265 X-rays were educed in 104 females and 161 males, and no fractures or wrist instability features were could be observed. The X-rays were obtained from computer lab and archive data base at St Hedwig Hospital in Trzebnica from the beginning of January 2011 to the end of December 2012. RESULTS: 196 cases (74%) were found with type I of the lunate and 69 cases (26%) with type II. Ulnar variance amounted to from +4.7 mm to -4.2 mm (mean value +0.9 mm). Positive ulnar variance was stated in 44 patients (16.6%), negative in 63 (23.7%) and neutral accounted for the biggest group of other 158 (59.7%) patients. CONCLUSIONS: Neutral variance of ulna is the one that occurs most often in the Polish population. There is no correlation between gender and ulnar variance. There is also lack of direct connection between occurrence of individual lunate types and ulnar variance.

Unusual coalition of the carpal bones with simian crease: a case report.

We present a case of scapholunate coalition with absent fifth metacarpal on one hand, and scapholunate triquetral coalition on the other hand. The patient was asymptomatic, though he was aware of the deformity of the little and ring fingers on the right hand. No treatment was offered as the deformity was not incapacitating and the syndactyly did not interfere with hand function.

Madelung's deformity: diagnostic thresholds of radiographic measurements.

PURPOSE: Although the x-ray changes of advanced Madelung's deformity are well described, little quantitative information exists on the subtle, early changes of the deformity. This study investigated the threshold of 4 radiographic measurements that predict a diagnosis of Madelung's deformity by experienced hand surgeons. METHODS: Ulnar tilt, lunate subsidence, lunate fossa angle, and palmar carpal displacement were measured on x-rays of patients with Madelung's deformity. For each set of x-rays 4 opinions were available concerning a diagnosis of Madelung's deformity as based on the x-rays only. The 4 quantitative measurements were examined to determine a threshold value that predicts a unanimous diagnosis of Madelung's deformity. RESULTS: The thresholds for the diagnosis of Madelung's deformity are: ulnar tilt of 33 degrees or greater, lunate subsidence of 4 mm or more, lunate fossa angle of 40 degrees or greater, and palmar carpal displacement of 20 mm or more. When any one of these measurements equaled or exceeded this threshold value, the raters were unanimous in establishing a diagnosis of Madelung's deformity. CONCLUSIONS: Threshold values of ulnar tilt, lunate subsidence, lunate fossa angle, and palmar carpal displacement for the diagnosis of Madelung's deformity are determined. Lunate fossa angle may prove especially useful in the diagnosis of early Madelung's deformity.

Radiographic spectrum of severity in Madelung's deformity.

PURPOSE: To establish whether Madelung's deformity demonstrates a radiographic continuum of severity and whether a forme fruste does exist. METHODS: Ulnar tilt, lunate subsidence, palmar carpal displacement, and lunate fossa angle were measured in 81 wrist radiographs with obvious or suspected Madelung's deformity. Statistical analyses based on these measurements were performed to ascertain if there is a deformity continuum. RESULTS: Ranges of 15 degrees to 51 degrees (mean, 28 degrees) for ulnar tilt, -7 to +11 mm (mean, -0.8 mm) for lunate subsidence, 9 to 25 mm (mean, 15.3 mm) for palmar carpal displacement, and 20 degrees to 56 degrees (mean, 33 degrees) for lunate fossa angle were obtained. Significant correlations were observed between all measurements. CONCLUSIONS: Madelung's deformity encompasses a spectrum of radiographic abnormality. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic I.

[Madelung deformity due to abnormal radiolunate ligament: report of 4 cases]. / Déformation de Madelung de l'enfant liée à la présence d'un ligament radio-lunaire anormal: à propos de 4 cas.

PURPOSE: To define the value of CT and MR in the demonstration of an abnormal radiolunate ligament contributing to a Madelung deformity and emphasize the features on wrist radiographs suggesting the presence of such ligament. OBSERVATIONS AND RESULTS: Four cases of adolescents presenting with uni- or bilateral wrist pain are reviewed. Standard radiographs demonstrated the present of isolated Madelung deformity with increased inferior radioulnar curvature with triangularization of epiphyses and decreased carpal angle. Each patient underwent either noncontrast CT, CT arthrography or MRI. All cross-sectional imaging studies demonstrated the presence of an abnormal radiolunate ligament with radial insertion within a bony gutter. Retrospectively, the bony gutter could be identified on radiographs. In two cases, excision of the ligament provided partial correction of the deformity and symptoms, without need for classical osteotomy. CONCLUSION: In patients with Madelung deformity, CT or better yet non-ionizing and noncontrast MR may demonstrate a abnormal radiolunate ligament within a bony gutter. Detection of this gutter on radiographs suggests the presence an abnormal ligament. Early release of the abnormal ligament appears to decrease wrist deformity, improve range of motion and reduce symptoms.

Incomplete scapholunate and trapeziotrapezoid coalitions with an accessory carpal bone.

Coalitions of the carpal bones associated with accessory carpal bones are relatively uncommon. We present a case of scapholunate and trapeziotrapezoid incomplete coalition with a dorsally situated accessory bone between trapezium and trapezoideum. X-ray, computed tomography, and magnetic resonance imaging findings of the patient are discussed in light of the pertinent literature.

Unilateral congenital absence of the lunate and scaphoid.

We report a patient with unilateral absence of the scaphoid and lunate bone of the wrist. Remarkably he had severe osteoarthritis in several other joints.

Ulnar variance and the shape of the lunate bone. A radiological investigation.

The authors designed a study to test the hypothesis that the length of the ulna might affect the shape of the lunate bone because of long-term molding during life. This might then be useful to predict the presence or absence of a dynamic or static ulna plus by the shape of the lunate bone. In a prospective study, posterior-anterior wrist x-rays were taken in a standard fashion in 68 patients with a mean age of 34.5 years. Dominance, grip strength, ulnar variance and the shape of the lunate were recorded. Lunate shape, type 1, which is the least molded, was seen most frequently on both the left and right side and did not correlate with the dominant side. The most molded, type 3, was seen less frequently and almost exclusively on the nondominant side. No correlation was found between dynamic ulna plus and the type 3 lunate. Following statistical analysis, no correlation between ulnar variance and lunate shape was found, indicating that the shape of the lunate bone had no predictive value for predicting the presence or absence of a dynamic ulna plus variance. The hypothesis that the length of the ulna might influence the ultimate shape of the lunate could not be demonstrated.

[Fracture of the lunatotriquetrum bone in the triquetral part. Case report and review of the literature]. / Fraktur eines Os lunatotriquetrum im triquetralen Anteil. Falldarstellung und Literaturäubersicht.

The fusion of the lunate and triquetrum is the most common type of carpal fusion. Fractures of the os lunatotriquetrum are rare and usually occur at the point of union. In our case we found an isolated transverse fracture of the triquetral part of the fused bone without dislocation. In case of non-union, the differential diagnosis of an incomplete fusion must be taken into consideration.

Symptomatic lunate-triquetral coalition.

Carpal coalitions are an uncommon anatomic anomaly caused by the failure of segmentation of the carpal cartilaginous anlage. The most common carpal coalition is between the lunate and triquetrum. Previously considered completely asymptomatic, carpal coalition and associated degenerative arthritis of the incompletely involved joints has been proven as a cause of occult wrist pain.

[The os lunato-triquetrum]. / Das Os lunato-triquetrum.

The os lunato-triquetrum is a fusion of the lunate with the triquetral bone. It is the most frequent anomalie of the carpe and nearly always asymptomatic. The coalition is mostly an isolated event or part of a syndrome of multiple anomalies. A case report of four patients with an synostosis between the lunate and the triquetrum is represented, two of them were members of African people. The high incidence in Africa and the geographical distribution of the described anomalie in black people of African descent are seen - under anthropological points of view - as ethnogenetic and ethnohistorical events.

[Bilateral lunato-triquetral synostosis with bilateral fracture of the scaphoid bone]. / Synostose bilatérale semi-lunaire-pyramidal avec fracture bilatérale des scaphoïdes.

The authors have treated a case of bilateral fracture of the scaphoid bone in a young man who had complete and bilateral lunato-triquetral synostosis, without any other associated congenital condition. Consolidation was obtained by orthopedic treatment on one side, but a Matti-Russe operation was necessary on the other. The authors emphasize but then rule out the hypothesis of a congenital bipartite scaphoid associated with the synostosis. A review of the literature on lunato-triquetral synostoses sums up the main points. The condition is rare in whites and occurs more frequently in blacks. It is sometimes associated with other congenital conditions. Four anatomic and radiologic types have been described. The pathogenic hypotheses, based on embryology, are summarized.